Volume 212 Issue 11

All countries must increase medical capabilities and adopt a concerted whole-of-government approach to combat COVID-19

Ray Junhao Lin · Tau Hong Lee · David CB Lye

During the COVID‐19 pandemic, people with heart disease are likely abandoning usual medical advice As the world watches the spread of the coronavirus disease 2019 (COVID‐19) pandemic, affecting the health of millions of people and the lives of everyone, common health conditions including heart disease, stroke, cancer and other chronic diseases continue. While there is no doubt that there are direct consequences for morbidity and mortality of COVID‐19, including its direct cardiovascular effects, it will be important to ensure that these are not matched by the indirect consequences. Countries are at different stages in the natural history of the pandemic, but there is a clear pattern. Overloaded health systems necessitate the hasty development of new protocols and pathways for common conditions that deviate from established guidelines and that may be caused by changes in community behaviour, either imposed or arising from fear. Unproven therapies are being tested in the field and, in the absence of evidence, there is the potential for theory to drive practice to an extent that is generally not seen in conditions with an established evidence base. During the COVID‐19 pandemic, emergency department (ED) attendances fell dramatically in England, with 89 584 attendances in the week after the lockdown (23–29 March 2020), down 25% compared with the 120 356 attendances during the previous week and almost 50% down on attendances in February 2020.1 This decrease in ED attendances has also been reported in Europe, Canada and Australia.2 ST elevated myocardial infarction (STEMI) rates fell by about 40% in reports from Austria3 and the United States.4 It is possible that COVID‐19 is associated with plaque stabilisation and lower rates of STEMI, but it seems more likely that people with heart disease are abandoning usual medical advice at a time when they may need it the most. In New York, US, a 50% decrease in ED visits for acute coronary syndromes has been reported at the same time as an eightfold increase in out‐of‐hospital cardiac arrest calls in the first week of April 2020.5 It is not clear how many of these calls are COVID‐19‐related, but there seems to be no doubt that people have a reluctance to attend hospital during the peak of the epidemic, which is having a significant cost in mortality. The angiotensin‐converting enzyme inhibitors and angiotensin II receptor blockers controversy In the midst of all this, a controversy has emerged about the safety and value of angiotensin‐converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) — commonly used for the treatment of hypertension and heart failure — in the context of the COVID‐19 pandemic. In ordinary times, these are considered to be among the safest, best tolerated and most effective drugs for the management of both hypertension and heart failure, with a strong evidence base showing a reduction in morbidity and mortality from these conditions.6,7 To date, there is insufficient clinical evidence that ACEIs, ARBs or other inhibitors of the renin angiotensin system are either harmful or beneficial in the acquisition of COVID‐19 or its subsequent clinical course in individual patients. A number of clinical trials of losartan and recombinant angiotensin‐converting enzyme 2 (ACE2) are underway, such as the Losartan for Patients with COVID‐19 Requiring Hospitalization trial (ClinicalTrials.gov, NCT04312009). The debate has arisen because of circumstantial arguments based on COVID‐19 pathophysiology and renin angiotensin system physiology.8,9 It is argued that ACEIs and ARBs may be harmful because: hypertension is overrepresented among people who develop the most severe complications of COVID‐19;10 severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) gains entry to a cell using ACE2 and type II transmembrane serine proteases;11 ACE2 is highly expressed in the cardiovascular system, gut, kidneys and lungs (in the cardiovascular system, ACE2 is expressed in cardiomyocytes, epicardial adipose tissue, cardiac fibroblasts, vascular smooth muscle and endothelial cells);11 ACEIs or ARBs upregulate ACE2 in heart cells in some experimental models;12 these factors in theory may lead to a greater viral load and more serious infection. Several important links in this logic chain are contested. Early reports of high rates of hypertension in people dying of COVID‐19 or presenting with severe COVID‐19 were not adjusted for age. However, it is clear that most of these patients have comorbidities, including hypertension, heart failure and diabetes, all of which are more common in an older population. The mortality rate in the intensive care unit in 72 regional hospitals in Lombardy, Italy, was 26%. Most patients were male (82%) and had extensive comorbidities, especially hypertension (49% overall and 62% of deaths).10 ACE2 and COVID‐19 pathophysiology The relationship between COVID‐19 and the renin angiotensin system has been reviewed extensively.11 Although there is no doubt that ACE2 is a receptor for COVID‐19 and that the gene is widely expressed in the body, there is mixed evidence on whether it is upregulated by ACEIs or ARBs in animal models, and there is no evidence that it is increased de novo in tissues that have low expression.13 COVID‐19 suppresses ACE2.11 If ACE2 expression is increased by ACEIs or ARBs, it does not necessarily imply that this enhances the ability of SARS‐CoV‐2 to infect cells. The affinity of the virus for ACE2 is very high, and it is not clear that a small increase in expression due to renin angiotensin inhibition would increase intracellular viral load. Another counterargument to this hypothesis is that an increase in ACE2 expression would provide a counter to the suppression due to SARS‐CoV‐2 and allow the beneficial effects of ACE2, including anti‐inflammatory activity, to manifest; that is, ACEIs or ARBs may be beneficial. Trial design to resolve the matter In considering the possibility of interactions between COVID‐19 and medications, it is important to take into account the different stages in the evolution of the disease in an individual. The earliest stages are characterised by mild or absent upper respiratory symptoms and lymphopenia. A minority of people infected with SARS‐CoV‐2 subsequently develop pneumonitis and pulmonary complications. Even fewer people develop the most severe complications with hyperinflammation — also called “cytokine storm” — often with myocarditis and other major organ failures. It is quite likely that the renin angiotensin system and, by implication, drugs that interact with it, such as ACEIs or ARBs, have different actions at various stages of the condition according to the tissues affected. For example, ACE2 is protective in acute lung injury, suggesting that, although it facilitates viral entry through the epithelium, the ACE2 and its product, the angiotensin (1‐7) axis, could be used to reduce tissue injury caused by SARS‐Cov‐2, a potential target for therapy.11 This will be an important consideration in the design and setting of clinical trials. What clinicians can do in the meantime There are highly circumstantial arguments for and against the use of ACEIs and ARBs in patients with COVID‐19 and there are many more in the literature — as preprints and on social media. In the absence of good epidemiological and clinical trial data, there is no immediate and definitive resolution to the debate. What is clear is that people with hypertension and heart failure benefit from ACEIs and ARBs where indicated, and withdrawing treatment is likely to have serious consequences in some people. We are thus left with a situation where stopping ACEIs or ARBs in some people has known and potentially serious sequelae, whereas continuing them in people with or vulnerable to COVID‐19 has unknown consequences that, depending on how the experimental evidence is interpreted, may be negative, neutral or even positive. International and national authorities on cardiovascular disease, including the High Blood Pressure Research Council of Australia, the World Health Organization, the American Heart Association and the European Society of Cardiology, have been united in their recommendation that treatments with ACEIs or ARBs should be continued during the present pandemic pending evidence from clinical studies to the contrary.14,15 In a number of patient groups, ACEIs or ARBs are first line choices; for example, in patients with hypertension and proteinuria or in people with heart failure. Given the clear benefits they have provided over several decades, a decision to withdraw first line therapies should only be based on reasons supported by a strong evidence base. In other groups, such as in patients with uncomplicated essential hypertension, there are alternatives, including calcium channel blockers or diuretics. However, changing medications in patients with well controlled blood pressure requires careful monitoring and there is a risk in the short term that blood pressure will fall outside the optimal range. This may prove challenging during a period when telemedicine is the norm and given that not all households have home blood pressure monitoring equipment and training. As the ACEIs and ARBs controversy has been wisely canvassed in the media, health professionals will need to have a conversation with patients about the benefits or otherwise of continuing their present therapies. It is important that people understand that no concerns have been raised about other medications they may be taking, such as statins, antithrombotic agents, or treatment for diabetes. In recommending continuation of ACEIs or ARBs, physicians can draw comfort that they are backed by almost every cardiovascular health authority in the world. Nevertheless, the clinical trial results of both administration or withdrawal of ACEIs or ARBs cannot come quickly enough, and in the best case, they will allow us to turn practice into the right theory.

Garry LR Jennings

An integrated approach that includes a central role for pathology laboratories is necessary Mass casualty events (MCEs) are defined as events or other circumstances “where the normal major incident response of one or several health organisations must be augmented by extraordinary measures to maintain an efficient, suitable and sustainable response”.1 Haemorrhage is a leading cause of mortality in MCEs, accounting for almost 50% of deaths in the first 24 hours,2,3 and transfusion emergency preparedness is increasingly recognised as a critical element of an integrated approach to MCEs,4 with timely availability and appropriate delivery of blood components being an essential part of management. On 20 January 2017, an MCE occurred in Melbourne, Victoria, when a car struck pedestrians in the Bourke Street Mall in the central business district, killing six people and injuring more than 30. The injured were taken to various adult and paediatric hospitals around Melbourne, including designated trauma centres and non‐trauma hospitals, both public and private. A Code Brown was activated at some of these hospitals. This is a hospital alert activated internally when notification of an external incident is received, usually by emergency services or health departments, which requires mobilisation of additional capability and capacity within that facility to receive an influx of patients.5 In Victoria, the users of blood products, including public and private hospitals and pathology laboratories, are represented by the Victorian Blood User Group. The Blood User Group meets quarterly with Australian Red Cross Lifeblood (previously Australian Red Cross Blood Service) to discuss issues relevant to the use and supply of blood products. In February 2017, Blood User Group members highlighted concerns with communication during the Bourke Street incident. Poor communication from hospitals to their pathology laboratories was noted during activation of hospital Code Brown alerts. There was also uncertainty and lack of transparency surrounding supply of blood components from Lifeblood to hospitals in Victoria, not only to those involved in the incident but also those awaiting delivery of routine blood inventory. In response to these concerns, the Blood User Group held a forum in August 2017 to discuss these issues and to make recommendations to assist planning for future incidents. Blood User Group representatives and invited guests, including National Blood Authority representatives, heard presentations from the Victorian Department of Health and Human Services, Lifeblood and four hospitals that received patients, outlining issues and learnings from the incident, followed by further discussion. A summary of recommendations was circulated to forum attendees. This article highlights issues and recommendations pertinent to hospitals and associated pathology laboratories, in particular their haematology and transfusion laboratories. Recommendations Pathology staff must form part of hospital critical incident management teams In some hospitals, the associated pathology laboratory is not part of the critical incident management team, and when these hospitals were notified of the Bourke Street MCE by emergency services, this was only communicated to the pathology laboratory via public address systems or other informal means. Updates received by hospitals from emergency services throughout the event were similarly not always communicated in a planned way. Key pathology representatives in some hospitals also attended their emergency departments in person, which was invaluable for communication but occurred on an ad hoc basis rather than being part of a documented protocol. Without streamlined communication, pathology representatives can often only respond to blood component requests and transfusion specimens when they arrive, leading to potential delays in blood product provision. As transfusion support remains a core component of management in MCEs, a key recommendation is that pathology staff must form part of any hospital's critical incident management team. This should be documented in the critical incident protocol, and involves active pathology staff participation during critical incidents. Further formalised pathology roles, such as physical attendance at critical sites in the hospital (eg, emergency department) to streamline communication with the laboratory, are also encouraged. This ensures that pathology services receive adequate notification of critical events, and enables direct involvement in ongoing management of the incident in a systematic way with clear lines of communication. It also allows pre‐emptive action such as pre‐thawing of clinical plasma, and review and management of current inventory including appropriate use of emergency blood components. Implement safe, non‐sequential allocation of unit record numbers for consecutive emergency patients One hazard noted at the forum was a lack of specific labelling protocols for identifying patients presenting to some emergency departments, resulting in potentially dangerous patient identifiers being used; for example, consecutive unit record numbers for consecutive patients, or the same prefix on all patients. This may facilitate clerical errors and patient misidentification. It is recommended that institutions ensure that allocation of unit record numbers for consecutive unknown patients is performed in a safe way, which minimises the risk of patient misidentification. Ensure adequate levels of pathology staff familiar with critical event management Staffing levels were an issue at some sites during the Bourke Street MCE, owing to senior staff being on leave. Similarly, when critical incidents occur after‐hours, staffing is often limited and senior personnel may not be on site, resulting in less experienced staff enacting their critical incident management plans. Extra staff may be required and there may be difficulty of access to workplaces if the incident results in road closures. Working during the incident can be physically and emotionally tiring, and replacement staff will be required after the event.4,6 Therefore, it is recommended that all staff, irrespective of experience, should be familiar with their local critical incident management plan, and that consideration be given to how staffing levels are managed during and after a critical incident. Include pathology staff in practice disaster scenarios All hospitals should practise responses to disaster scenarios and involve pathology representatives. During the Bourke Street event, hospitals other than the major trauma centres received multiple casualties. “Walking wounded” may also present at nearby hospitals, irrespective of whether these have emergency departments. Performing practice scenarios is therefore important to familiarise staff with their critical incident plans. Limitations of these scenarios are recognised, as they often do not encompass the practical issues faced by pathology teams, such as time taken to run multiple pathology samples, perform multiple crossmatches and accept into inventory large numbers of blood products. Despite these limitations, it is recommended that hospitals perform practice disaster scenarios and involve pathology staff to highlight areas of potential weakness. Consider standby phase in Code Brown responses One hospital activated their Standby Code Brown during the Bourke Street MCE, when it was first notified by emergency services of the possible arrival of casualties, but before patient numbers or severity of injuries were known. This standby phase alerted the critical response areas of the hospital, including the emergency department and pathology services, to an external incident, allowing review of department response plans such as staffing levels and blood product inventory without activating a full Code Brown response. The standby code remained in place until the hospital was advised of further details of presenting patients. It is recommended that hospitals incorporate such a standby phase in their emergency response plan. This alerts relevant departments to plan and prepare for escalation of an event when a critical incident is first notified to the hospital, but before further details are known or casualties have presented, without activating the full series of Code Brown activities which can be disruptive. Discussion Effective communication during MCEs is critical. It is common for many more blood components to be requested than are eventually transfused, and the overall requirement for products in these events is often lower than expected.7,8 Most blood use in MCEs occurs within the first 24 hours, particularly in the first 4 hours as the majority of severe casualties arrive within this time frame.2,7 Therefore, the key to managing these chaotic and rapidly evolving events is early, accurate and ongoing updated communication between emergency services, state health departments, hospitals, pathology laboratories and Lifeblood to ensure that blood components are urgently allocated to appropriate patients while limiting unnecessary ordering and cross‐matching of products. Local communication between hospital departments and pathology laboratories can be improved by implementing the above recommendations, in particular by involving pathology laboratories in critical incident management. Hospitals may use existing communication channels including email, intranet and paging or other messaging services; however, the protocol for using these should be clearly documented in the critical incident management plan. Broader statewide communication via health departments and Lifeblood would also allow other health care services to respond appropriately; for example, by managing blood inventory conservatively until the extent and impact of the MCE is known. This requires effective communication between health departments and Lifeblood, and it is imperative that information circulated via state jurisdictions and Lifeblood is consistent to avoid confusion. Forum attendees recommended that the National Blood Authority enable Lifeblood to disseminate information to pathology services through a web‐based blood product ordering system, BloodNet, which is used by transfusion laboratories throughout Australia. Health departments should similarly ensure that existing channels for communicating emergency information to hospitals, such as hospital personnel contact details, are current. Any communication must also be effective outside standard business hours. Fax or email messages are unreliably received after‐hours, and phone contact with appropriate hospital personnel may be more effective. The Bourke Street Mall MCE highlighted the challenges involved in supplying blood components during such events. The recommendations are similar to those published in a previous review on transfusion preparedness for MCEs4 and recognise the requirement for an integrated approach that includes a central role for pathology laboratories. Incorporating the lessons learnt from this incident will allow for more organised responses and streamlined communications between all departments and institutions.

Linda Saravanan · Amanda Ormerod

The existing system is failing to deliver the care that Australia expects Australia's aged care has changed considerably in recent decades. In response to consumer demand, old institutional‐style nursing homes have been progressively phased out in favour of better facilities. Home‐like furnishings and decor and single bedrooms personalised with residents’ own belongings have increasingly become the norm. In the process, they have become residential aged care facilities (RACFs), and there is no longer a distinction between low and high care.1 At the same time, older people want to stay in their own homes longer and have increasingly been able to do so because more community care is now available. Along with significant accommodation bonds and other charges, this has also served government objectives of reigning in the costs of Australia's ageing population.1 Contemporary residential care is no longer a lifestyle choice, it is now primarily for people who can no longer live at home. However, funding and staffing have not kept pace with this change.1 Aged care residents’ needs People living in RACFs now are typically very frail and have complex physical, cognitive and social care needs. During 2018, we independently assessed 5000 people living in RACFs.2 Only 15% of residents were independently mobile, one in two (50%) required mobility assistance, and over a third (35%) were not mobile. The bedridden group was at greatest risk of pressure injuries. People living in RACFs are vulnerable; the typical resident lacks energy and struggles with everyday activities. Most residents (> 80%) need help with activities such as showering, getting dressed or using the toilet. Moreover, many residents have memory, understanding and communication problems. Almost half of the residents find it difficult to interact with others and may become distressed when care staff try to assist them with personal hygiene, for example. Mental health problems are rife. Agitation is the most prevalent problem (43%), followed by depression (35%) and irritability (35%).3 There are about 180 000 residential care beds in Australia occupied on any one day by permanent residents.4 About 60 000 permanent residents die each year and about the same number take their place.5,6 The number of residents who die in their RACF is unclear. What is known is that many thousands are transferred to hospital due to staff not having the skills, confidence, capacity, resources or back‐up to provide the care they need.7 Neglect, the recently released interim report of the Royal Commission into Aged Care Quality and Safety, concluded that “substandard care is much more widespread and more serious than … anticipated”.7 Staffing in residential aged care facilities To inform its work, the Royal Commission requested a research study be carried out into residential care staffing.1 This involved a review of staffing standards internationally and an assessment of current Australian staffing levels against international and national standards. Australian staffing levels were calculated based on a time and motion study we conducted in 2018.3 Residents in Australia receive on average 188 minutes of care per day, which includes 36 minutes by registered nurses, 8 minutes by allied health professionals (mostly physiotherapists) and 144 minutes by personal care assistants.1 Anecdotally, registered nurses and allied health professionals are required to spend a disproportionate amount of time on paperwork for funding purposes, leaving even less time to spend on care. Adequate care time and staffing mix and levels So how can we tell if a RACF is providing adequate care time and has the right mix of staff? Our Royal Commission research considered these questions.1 The international literature consistently reports that staff time requirements are driven by resident function, cognition, behaviour and technical nursing requirements, and our 2018 research confirmed that these same drivers apply in Australia.3 The clear evidence in the international literature of a direct causal relationship between staff numbers and skill mix and resident safety and quality outcomes is equally applicable to Australia.8,9,10 Over 150 studies documented in systematic reviews, primarily from the United States, Canada, the United Kingdom and northern Europe, confirm a “strong positive impact of nurse staffing on both care process and outcome measures”.11 Organisational factors, such as professional staff mix (ratio of registered nurses to total staffing levels), staff turnover rates, use of agency staff, and consistency in staffing also have an impact on quality. We found that the five‐star rating system used in the US by the Centers for Medicare and Medicaid Services (CMS) is the most relevant system internationally for judging aged care in Australia. It has a strong evidence base and has been in widespread use for nearly 20 years.12 While it does not address allied health staffing levels, it could be developed to do so if such an approach were adopted in Australia. The CMS considers the amount of care time provided to residents by nursing and personal care staff and adjusts this according to the needs of residents in each home. The outcome is a rating of between one and five stars. The more stars the better. The five‐star threshold is the point at which there is no evidence of any additional quality improvements for residents (Box).12 As seen in the Box, Australian RACFs rate poorly compared with US RACFs. They also do badly compared with the standards in place in Germany and Canada and with the standards set down by the state governments of Victoria and Queensland.1 Research into the CMS system found that homes are more likely to “experience quality concerns” when staffing levels fall below a certain level.12 This threshold is equivalent to the minimum requirement for a three‐star rating (ie, 30 minutes of registered nurse time and 215 minutes of total time). Therefore, we determined that anything less than three stars is inadequate for Australian RACFs.1 Using these metrics, more than half of all Australian aged care residents (57.6%) are in RACFs that have inadequate (one or two stars) staffing levels. A little over a quarter (27.0%) are in RACFs that have three stars, 14.1% of residents are in RACFs with four stars, and 1.3% are in RACFs with five stars, which we consider best practice.1 Bringing all RACFs in Australia up to at least three stars would require an average staffing increase of 37.3% in those RACFs currently rated one or two stars, which would result in an overall increase of 20% in total care staffing across Australia. Achieving four stars would increase total staffing by 37.2% and five stars by 49.4%. Importantly, these increases are total numbers for the sector as a whole and need to be adjusted according to the mix of residents when applied to individual RACFs.1 The best international benchmark for allied health staff currently is from the Canadian province of British Columbia, which recommends a minimum of 22 minutes of allied health services per resident per day. Only 2% of Australian aged care residents currently receive this level of care. An additional 175% in allied health staffing is required to achieve this international standard.1 The evidence is clear Our research was requested by the Royal Commission against a background of numerous examples of poor quality care experienced by older people living in RACFs.1 A recurring theme has been the lack of staffing to meet the wide‐ranging and increasingly complex needs of residents — assertions that have been supported by the results of our research.1 It is clear from our research and from the evidence presented to the Royal Commission that there is a compelling case for additional resources in RACFs. This includes improving the staffing mix and increasing staffing levels to an acceptable standard. As the Royal Commission's interim report notes,7 the existing system has failed to ensure residents receive quality care. It is no longer acceptable to describe RACFs simply as a person's home or for advocates to argue that what is required is a social model of care delivered with a wellness philosophy.13,14,15 While on the surface it sounds attractive and in line with what consumers want, the evidence from the Royal Commission is that these arguments are now being used as a justification for inadequate care.7 Conclusion Residents in Australian RACFs have a right to be safe and to receive clinically competent and adequate care. This care needs to be provided within a non‐institutional environment that is respectful of individual choices and affords every resident the opportunity to be meaningfully engaged to the extent possible. There does not need to be a trade‐off between a social model of care and a clinically competent model. Aged care residents have a right to both and do not have the time to wait. Box – Star rating system for aged care facilities: comparison between Australia and the United States

Kathy Eagar · Anita Westera · Conrad Kobel

The use of defibrillators for ventricular arrhythmias may significantly reduce mortality when sudden cardiac death is the major contributor The 2018 guidelines from the National Heart Foundation and the Cardiac Society of Australia and New Zealand provide evidence‐based direction for the management of heart failure in Australia.1 A Perspective article published in the Journal in 20192 challenged the weak recommendation for the implantation of a defibrillator in the primary prevention of mortality in dilated cardiomyopathy (DCM) with a left ventricular ejection fraction (LVEF) of 35% or below.1 The authors of the MJA article2 questioned the differences between this recommendation1 and recent Canadian and American guidelines.3,4 We welcome this opportunity to clarify the basis for the Australian guidelines recommendation. To understand the heart failure disease process, it is fundamental to recognise the differences in mechanisms of death and prognosis in ischaemic cardiomyopathy (ICM) versus DCM. Sudden cardiac death is more frequently responsible for mortality in ICM compared with pump failure and death from non‐cardiac causes in DCM. As such, defibrillators that provide shocks for ventricular arrhythmias are expected to significantly reduce mortality when sudden cardiac death is the major contributor. Combined with recent clinical trial data, this is the foundation for the current guidelines in primary prevention, making a strong recommendation for a defibrillator in reducing mortality in ICM compared with a weak recommendation for DCM.1 The GRADE methodology (www.gradeworkinggroup.org) used in these guidelines ensures that the strength of a recommendation not only takes into account the quality of evidence but also the benefits and harms of an intervention, improvements in quality of life, longevity, patient preferences, and resource considerations. The contrasting prognoses of the two major underlying causes for systolic heart failure is demonstrated in the outcomes of clinical trials exploring the role of primary prevention defibrillators. The MADIT‐II trial found a significant reduction in mortality in ICM with an ejection fraction of 30% or below (P = 0.016).5 In contrast, there have been no randomised controlled trials demonstrating a significant reduction in total mortality with implantable cardioverter defibrillators (ICDs) in DCM. On the basis of the SCD‐HeFT trial,6 ICDs were recommended in patients with heart failure with reduced ejection fraction with an LVEF below 35% regardless of underlying coronary artery disease, despite the absence of statistical significance in DCM. The 2016 DANISH study randomly allocated 1116 patients with DCM and a LVEF below 35% to ICDs versus medical therapy, with no significant difference in total mortality.7 Importantly, there were higher rates of optimised medical therapy compared with earlier randomised ICD studies, and cardiac resynchronisation therapy was included in 58% of patients. The limitations of the DANISH trials suggested in the MJA article,2 such as the optimised medical treatment and low mortality, are strengths and more accurately reflect the expected outcomes in a contemporary DCM population who receive guideline‐directed medical therapy. Nonetheless, despite the absence of positive randomised controlled trials, recent meta‐analyses, with the inclusion of DANISH, continue to demonstrate a significant mortality reduction for primary prevention defibrillators in DCM.8 While meta‐analyses provide an analytical technique to pool results and inflate sample sizes to improve statistical power, there are important limitations. Biases related to study selection, publication bias, heterogeneity of study populations in relation to treatment, follow‐up, and study time points have an impact on the findings of meta‐analyses, despite attempts at statistical corrections. Early primary prevention ICD studies were stopped prematurely due to futility and, as such, contribute little to meta‐analyses.9 The inclusion of older studies in undertreated medical patients with the variable inclusion of cardiac resynchronisation therapy is an important limitation in the interpretation of meta‐analyses investigating primary prevention ICDs in DCM. Implanting physicians are cognisant of potential harm, with Australian data reporting ICD‐related complications requiring rehospitalisation or re‐operation in 10% of patients.10 Battery longevity and defibrillator lead durability are additional considerations. Careful patient selection is required to identify patients with DCM likely to benefit from ICD therapy. The 2018 Australian guidelines draw attention to the increased efficacy of ICD therapy in patients younger than 70 years identified as a pre‐specified endpoint in the DANISH study.11 Although the incidence of sudden cardiac death did not differ between age groups, the incidence of non‐sudden cardiac death becomes significantly higher in the older population. Our recommendation is supported by a recent clinical practice update from the Heart Failure Association of the European Society of Cardiology. Providing specific recommendations regarding subpopulations, such as patients with infiltrative or hypertrophic cardiomyopathy, was beyond the scope of the 2018 national guidelines. As we await better tools for risk stratification of patients with DCM, supportive data from randomised controlled trials and improvements in pharmacological and device‐based heart failure therapy, the weak recommendation for ICDs for the primary prevention of mortality1 provides the support for a considered decision between patient and physician, balancing the absence of randomised controlled trial data with the morbidity of an ICD implant. “It is precisely where evidence is lacking or is controversial that clinicians need the most guidance.”12

Peter M Kistler · John J Atherton · Garry Jennings

Clinical record A 70‐year‐old man with multiple myeloma was admitted to our hospital in 2018, having been hospitalised 10 months previously in the United Kingdom. Following admission to our facility, routine collection of clinical specimens was performed in the setting of an episode of febrile neutropenia. Candida auris was isolated in a urine specimen collected in the presence of an indwelling urinary catheter, without accompanying pyuria. Screening of ward contacts (n = 73) was subsequently performed by collection of composite axilla and groin skin swabs, together with swabbing of possible clinical sites of infection (eg, wounds, catheter sites). Swabs were plated onto Candida chromogenic agar and incubated aerobically for 48 hours at 35°C. Any colonies not typical for C. albicans or C. tropicalis were identified using matrix‐assisted laser desorption ionisation time‐of‐flight (MALDI‐TOF) mass spectrometry. The routine regimen of daily cleaning and disinfection of rooms with 1000 ppm sodium hypochlorite solution was continued. Enhanced infection control measures, including contact precautions and single‐room isolation were instituted. A multidisciplinary taskforce coordinated screening, laboratory and prevention strategies. Review of laboratory reports for the preceding 12 months confirmed this to be the first documented C. auris isolate at our facility. One ward contact, a 38‐year‐old man with diffuse large B cell lymphoma, was identified as colonised with C. auris. The organism was detected in a urine specimen collected in the presence of a long term indwelling urinary catheter. This patient had been admitted to a health care facility in the United Arab Emirates, before direct transfer to our facility about 3 months earlier. Colonised patients had been located in a common ward for 19 days, each in a single room with dedicated bathroom and patient care equipment. They had also been managed on an outlying ward for brief periods (3 and 2 days, respectively) separated in time by 2 days. Neither patient developed clinical features of urinary tract or disseminated C. auris infection and antifungal therapy was not administered. Isolates were confirmed as C. auris by MALDI‐TOF mass spectrometry (each with score of 1.75). Antifungal susceptibility testing by broth microdilution demonstrated isolates were resistant to fluconazole (minimum inhibitory concentration [MIC] > 256 mg/L) and susceptible to caspofungin (MIC, 0.25 mg/L) and anidulafungin (MIC, 0.12 mg/L for Patient 1 and 0.25 mg/L for Patient 2). To investigate relatedness of isolates, whole genome sequencing and bioinformatics analysis were performed. Phylogeographic analysis demonstrated that both were related globally to those contained in the India–Pakistan clade. The median pairwise single nucleotide polymorphism distance between the two isolates was 167, suggesting that while these isolates were related, it was not possible to confirm whether transmission had occurred. Discussion Candida auris is an emerging, drug‐resistant yeast, responsible for hospital outbreaks internationally.1 First recognised as a new species of Candida in 2009, cases have been reported in over 30 countries, including the United Kingdom and United Arab Emirates.1,2 In outbreak settings, bloodstream, urinary tract and deep tissue infections have been reported, in addition to colonisation. The majority of isolates are fluconazole resistant,3 with variable resistance to amphotericin B and the echinocandin class of antifungal agents. Infection is associated with a crude mortality of 30%.3 Key differences between C. albicans (the most frequently identified Candida species in Australia) and C. auris are summarised in the Box. Risks for C. auris acquisition include admission to a high dependency unit, presence of invasive medical devices, underlying immunocompromise or chronic disease and receipt of antibiotic or antifungal agents.4 One case of C. auris invasive disease has previously been reported in Australia,5 but to our knowledge the two cases identified at our facility represent the first possible transmission of C. auris in Australia. Identification of C. auris is challenging, with potential misidentification by routine biochemical methods. If C. auris is included in the reference profile database, MALDI‐TOF mass spectrometry may be used to confirm diagnosis. DNA sequencing also provides confirmation, together with data regarding origins and potential transmission in health care settings.3 Collection of bilateral axilla and groin skin swabs as a combined screening specimen is recommended for optimal yield.6 European and United States guidelines recommend screening of all room contacts of patients with C. auris.6,7 Screening of additional patients (eg, whole ward) is necessary where more than one case is identified. Targeted surveillance of patients who have recently had at least one overnight stay in an overseas facility is also recommended, especially if from a country reporting C. auris cases.6,7 Our experience highlights the importance of this strategy. Clinicians should be aware of risks for C. auris acquisition, including overseas health care encounters. In high risk settings, and where a case of C. auris infection has been identified, timely screening of patients is required to ensure that appropriate control measures are instituted. Lessons from practice Candida auris is an emerging drug‐resistant yeast, now reported in Australian health care facilities. In contrast to C. albicans, which is commonly isolated in community and health care settings, C. auris is generally only identified in high risk hospitalised populations. Risks for acquisition include intensive care or high dependency unit admission, presence of invasive medical devices, underlying immunocompromise or chronic disease, and receipt of broad spectrum antibiotics or antifungal agents. Strict infection control measures, including contact precautions and isolation, are required to reduce risks of transmission. Screening for colonisation is an important element of infection control strategies, and a composite skin swab of axilla and groin is recommended. Timely detection requires laboratory identification. MALDI‐TOF mass spectrometry may be used for confirmation, and whole genome sequencing may provide additional information on possible transmission events. Health care facilities must ensure processes are implemented for screening of patients who have received health care in overseas hospitals. Box – Comparison of clinical and epidemiological characteristics of Candida albicans and Candida auris Candida albicans Candida auris Colonisation Colonisation of patients in community and health care settings is common; a commensal of skin and gut of immunocompetent and immunocompromised hosts Colonisation of patients associated only with hospital outbreaks or transmission, also identified in environment and equipment in hospital outbreak settings Infection Infection most frequently at mucosal sites (eg, oropharyngeal, vulvovaginal); bloodstream and urinary tract infections less frequent Bloodstream, urinary tract and wound infections reported Risks for infection ICU or HDU admission, invasive medical devices, major abdominal surgery, solid tumours, haematological malignancies, broad spectrum antibiotics ICU or HDU admission, invasive medical devices, underlying immunocompromise or chronic disease (eg, diabetes, chronic lung disease, renal failure, cardiovascular disease, or malignancy), broad spectrum antibiotics or antifungal agents Geographical distribution Ubiquitous, community and health care settings Reported only in health care settings, expanding global distribution Laboratory identification Culture using selective chromogenic media Culture together with MALDI‐TOF or DNA sequencing Antifungal resistance Generally susceptible to fluconazole Resistance to fluconazole is likely* HDU = high dependency unit; ICU = intensive care unit; MALDI‐TOF = matrix‐assisted laser desorption ionisation time‐of‐flight mass spectrometry. *Note: agreed fluconazole minimum inhibitory concentration breakpoints for C. auris have not been established

Leon J Worth · Simon J Harrison · Michael Dickinson · Annaliese Diemen · Jennifer Breen · Susan Harper · Caroline Marshall · Deborah A Williamson · Karin A Thursky · Monica A Slavin

The available tools are largely unregulated, and do not reliably guide people to the right care at the right time

Adam G Dunn

Bladin CF, Kim J, Bagot KL, et al. Improving acute stroke care in regional hospitals: clinical evaluation of the Victorian Stroke Telemedicine program. Med J Aust 2020; 212: 371–377. https://doi.org/10.5694/mja2.50570. In Box 2 of this article, the heading should read “Control”, not “Contriol”; the author affiliation 3 should read “Monash University, Melbourne, VIC.”, not “Monash Health, Monash University, Melbourne, VIC.”

Objectives: To investigate the quality of diagnostic and triage advice provided by free website and mobile application symptom checkers (SCs) accessible in Australia. Design: 36 SCs providing medical diagnosis or triage advice were tested with 48 medical condition vignettes (1170 diagnosis vignette tests, 688 triage vignette tests). Main outcome measures: Correct diagnosis advice (provided in first, the top three or top ten diagnosis results); correct triage advice (appropriate triage category recommended). Results: The 27 diagnostic SCs listed the correct diagnosis first in 421 of 1170 SC vignette tests (36%; 95% CI, 31–42%), among the top three results in 606 tests (52%; 95% CI, 47–59%), and among the top ten results in 681 tests (58%; 95% CI, 53–65%). SCs using artificial intelligence algorithms listed the correct diagnosis first in 46% of tests (95% CI, 40–57%), compared with 32% (95% CI, 26–38%) for other SCs. The mean rate of first correct results for individual SCs ranged between 12% and 61%. The 19 triage SCs provided correct advice for 338 of 688 vignette tests (49%; 95% CI, 44–54%). Appropriate triage advice was more frequent for emergency care (63%; 95% CI, 52–71%) and urgent care vignette tests (56%; 95% CI, 52–75%) than for non‐urgent care (30%; 95% CI, 11–39%) and self‐care tests (40%; 95% CI, 26–49%). Conclusion: The quality of diagnostic advice varied between SCs, and triage advice was generally risk‐averse, often recommending more urgent care than appropriate.

Michella G Hill · Moira Sim · Brennen Mills

The negative impact of cannabis use by pregnant women is independent of tobacco use

Luke E Grzeskowiak · Jessica A Grieger · Prabha Andraweera · Emma J Knight · Shalem Leemaqz · Lucilla Poston · Lesley McCowan · Louise Kenny · Jenny Myers · James J Walker · Gustaaf A Dekker · Claire T Roberts

Out‐of‐pocket expenses for cancer care are of growing concern for patients, clinicians, service providers, non‐governmental organisations, private insurers, and politicians. Contrary to popular belief, there is no direct link between the cost and quality of care. Out‐of‐pocket expenses are a particular problem for patients who live further from treatment centres, are younger, or have later stage disease.1 Adults (18 years or older) with pathologically confirmed colorectal, lung, prostate or breast cancer from four rural (Midwest, South West, Great Southern, Goldfields) and two outer metropolitan (Joondalup/Wanneroo and Rockingham/Peel) regions of Western Australia were identified in the WA Cancer Registry. Between 1 April 2014 and 31 April 2017, eligible patients were invited to complete questionnaires requesting demographic, financial, and treatment information, including all costs during treatment, as reported previously.2 We used log‐linked generalised linear models with gamma distribution, adjusted for age and sex, to estimate out‐of‐pocket expenses (with 95% confidence intervals [CIs]) for participant characteristics found to be significantly associated with out‐of‐pocket expenses in univariate analyses (online Supporting Information). The study was approved by the WA Country Health Service Ethics Committee (reference, 2014:10) and the Department of Health WA Human Research Ethics Committee (reference, 2014/26). One hundred and seventeen of the 119 outer metropolitan participants (98%) and 294 of the 308 rural participants (95%) incurred out‐of‐pocket expenses for their cancer care, chiefly for surgery, medical tests, and medical appointments. These costs ranged between $51 and $106 140 for outer metropolitan participants, and between $13 and $20 842 for rural participants. Fifty‐three rural participants (17%) and 39 outer metropolitan participants (33%) spent more than 10% of their household income on cancer care (data not shown). Among rural participants, mean out‐of‐pocket expenses were higher for men ($1988; 95% CI, $1605–$2461 v $1362; 95% CI, $1092–$1699), for people with private health insurance ($2455; 95% CI, $1973–$3053 v $1103; 95% CI, $877–$1386), and for people who were married ($2086; 95% CI, $1749–$2489 v $1297; 95% CI, $975–$1725), had undergone surgery ($1990; 95% CI, $1684–$2351 v $1360, 95% CI, $1005–$1839), or had worked prior to being diagnosed with cancer ($2084; 95% CI, $1643–$2644 v $1298; 95% CI, $1038–$1625) (Box). Among outer metropolitan participants, mean out‐of‐pocket expenses were higher for men ($5217; 95% CI, $3928–$6928 v $2247; 95% CI, $1756–$2875), for people with private health insurance ($4670; 95% CI, $3588–$6078 v $2510; 95% CI, $1853–$3401), and for those who had undergone surgery ($5434; 95% CI, $4260–$6932 v $2157; 95% CI, $1541–$3020), worked prior to being diagnosed with cancer ($5471, 95% CI, $3952–$7573 v $2143; 95% CI, $1643–$2794), resided in areas of high socio‐economic status ($4299; 95% CI, $3235–$5712 v low, $1859; 95% CI, $1374–$2516), or were receiving chemotherapy ($4286; 95% CI, $3162–$5810 v $2735; 95% CI, $2116–$3534) (Box). It is perhaps surprising that out‐of‐pocket expenses were higher for people in outer metropolitan areas, who presumably lived closer to treatment centres than rural residents. However, these findings are consistent with the recent report that out‐of‐pocket spending on non‐hospital Medicare‐subsidised services and specialist services was higher for metropolitan patients than for those in regional areas.4 The higher out‐of‐pocket expenses for people with private health insurance or undergoing surgery indicate the importance of health care funding arrangements and the magnitude of the costs borne by patients. The marked variation in out‐of‐pocket expenses reported here and by others5 highlights the need for easily accessible information about services, medical costs, and gap payments for all health care services. The Informed Financial Consent website coordinated by the Australian Medical Association,6 consumer organisation fact sheets, and professional body initiatives are steps in the right direction, but their impact is yet to be determined. Problems that still need attention in the unregulated private fee‐setting environment in Australia include price discrimination in some specialist sectors.7 Bundles of care for cancer treatment that would allow patients and their families to better understand and plan for expenses should be explored. Box – Estimated mean out‐of‐pocket expenses for cancer‐related health care (with 95% confidence intervals) for outer metropolitan and rural patients, by patient characteristics significantly associated with higher out‐of‐pocket expenses in univariate analyses* * For outer metropolitan patients, marital status, and for rural patients, socio‐economic status and chemotherapy were not significant predictors of out‐of‐pocket expenses, and were therefore not included in the final models. †Index of Relative Socio‐economic Disadvantage (IRSD):3 low (most disadvantaged), deciles 1–4; moderate, deciles 5–6; high (least disadvantaged), deciles 7–10.

Neli S Slavova‐Azmanova · Jade C Newton · Christobel M Saunders

The conventional treatment for brain metastases is whole brain radiotherapy (WBRT).1 But there has been a gradual move to managing limited brain metastases with stereotactic radiosurgery (SRS),2 and delaying or avoiding WBRT because of its effects on cognition and quality of life. Data on contemporary SRS practice for managing brain metastases in Australia are, however, very limited.3 We performed a population‐based linkage study, analysing data from the Victorian Cancer Registry and the Victorian Radiotherapy Minimum Data Set (VRMDS). We included all patients with solid tumours (ICD‐10 codes C00–C80), but excluding primary central nervous systems malignancies (ICD‐10 codes C69–72), who received brain radiotherapy in Victoria between 1 January 2012 and 31 December 2017. The primary outcome was the proportion of patients treated with SRS. Although SRS refers to large single fraction radiotherapy, patients treated with fractionated “stereotactic radiotherapy” were also classified as receiving SRS. In addition, because of potential coding inconsistencies, patients who had no more than four fractions of radiotherapy and were treated with “volumetric modulated arc therapy” or “intensity modulated radiation therapy” were also classified as receiving SRS. Differences in factors of interest by SRS use were assessed in Pearson χ2 (categorical variables) and Student t or Mann–Whitney U tests (continuous variables). Temporal changes were assessed with the Cochran–Armitage test for trend. Factors associated with SRS use were assessed by logistic regression, with year as an ordinal categorical variable; variables for which P < 0.10 in univariate analyses were included in the multivariate model. The study was approved by the Austin Health Human Research Ethics Committee (reference, LNR/18/Austin/34). A total of 3961 patients who received radiotherapy for brain metastases were included, of whom 1116 (28%) received SRS. The proportion of patients receiving SRS increased from 27% (105 of 388) in 2012 to 35% (287 of 821) in 2017 (for trend: P < 0.001). The mean age of patients who received SRS (63.5 years; standard deviation [SD], 12.5 years) was lower than for those who did not (65.2 years; SD, 12.5 years). Factors that influenced SRS use included socio‐economic status, primary cancer type (about half the patients with melanoma received SRS, and about one‐quarter of patients with other cancer types), treatment institution type (public institutions, 31%; private institutions, 24%), and location (metropolitan centres, 34%; regional centres, 5%). Remoteness of patients’ area of residence was not a significant factor. In multivariate analyses, age, primary cancer type, treatment centre type, and location were significant factors for SRS use (Box). While the VRMDS captures all radiotherapy delivered in Victoria, it does not include data on patients’ performance status, numbers of brain metastases, the extent of extracranial disease, and other factors that would allow evaluation of the appropriateness of SRS for individual patients. Another limitation is potential misclassification of radiotherapy classified as “SRS”, as the VRMDS did not include data on radiotherapy dose. As evidence supporting the use of SRS for managing brain metastases grows, we would expect SRS rates to rise.6,7 While SRS was less frequently used in regional centres, patients living in regional areas were as likely to receive SRS as patients living in metropolitan areas. It is nevertheless important to ensure easy and convenient access to SRS services for all cancer patients in Victoria. Box – Baseline characteristics of 3961 patients who received radiotherapy for brain metastases, Victoria, 2012–2017 Stereotactic radiosurgery Multivariable analysis: odds ratio (95%CI) P Received Not received Number of patients 1116 (28%) 2845 (72%) Age at first treatment for brain metastases (years) < 55 266 (33%) 543 (67%) 1 55–59 157 (32%) 331 (68%) 1.11 (0.86–1.44) 0.42 60–64 161 (28%) 419 (72%) 0.89 (0.69–1.14) 0.35 65–69 177 (26%) 502 (74%) 0.85 (0.67–1.08) 0.19 70–74 153 (25%) 448 (75%) 0.88 (0.68–1.14) 0.33 75 or more 202 (25%) 602 (75%) 0.78 (0.62–0.99) 0.045 Mean (SD) 63.5 (12.5) 65.2 (12.5) — — Sex Men 528 (28%) 1373 (72%) — — Women 588 (29%) 1472 (71%) — — Primary cancer type Lung 419 (24%) 1344 (76%) 1 Breast 203 (28%) 512 (72%) 1.24 (1.00–1.53) 0.05 Melanoma 252 (47%) 277 (52%) 2.89 (2.32–3.59) < 0.001 Gastrointestinal 93 (28%) 235 (72%) 1.37 (1.03–1.80) 0.028 Genitourinary 73 (28%) 189 (72%) 1.33 (0.97–1.80) 0.07 Other 76 (21%) 288 (79%) 0.80 (0.60–1.06) 0.12 Socio‐economic status (quintile) 1st (most disadvantaged) 188 (24%) 612 (77%) 1 2nd 189 (27%) 501 (73%) 1.12 (0.87–1.44) 0.39 3rd 202 (26%) 572 (74%) 1.02 (0.79–1.30) 0.90 4th 220 (26%) 618 (74%) 0.90 (0.70–1.14) 0.38 5th (least disadvantaged) 317 (37%) 542 (63%) 1.19 (0.94–1.50) 0.14 Remoteness classification5 Major city 780 (29%) 1949 (71%) — — Inner regional 261 (26%) 732 (73%) — — Outer regional/remote/very remote 75 (31%) 164 (69%) — — Treatment institution type Public 744 (31%) 1656 (69%) 1 Private 372 (24%) 1189 (76%) 0.10 (0.07–0.14) < 0.001 Treatment institution location Metropolitan 1071 (34%) 2071 (66%) 1 Regional 45 (5%) 774 (95%) 0.58 (0.49–0.68) < 0.001 Year of first brain metastasis treatment 2012 105 (27%) 283 (73%) 1 2013 111 (25%) 342 (76%) 1.01 (0.72–1.41) 0.95 2014 147 (25%) 439 (75%) 0.86 (0.63–1.18) 0.35 2015 207 (25%) 633 (75%) 0.79 (0.59–1.06) 0.12 2016 259 (30%) 614 (70%) 1.10 (0.83–1.47) 0.50 2017 287 (35%) 534 (65%) 1.41 (1.06–1.88) 0.017 CI = confidence interval; SD = standard deviation. * Index of Relative Socio‐Economic Disadvantage.4

Wee Loon Ong · Therese Ming Jung Kang · Gishan Ratnayake · Morikatsu Wada · Jeremy Ruben · Sashendra Senthi · Roger L Milne · Jeremy L Millar · Farshad Foroudi

Psoriasis is a chronic inflammatory disease that is commonly encountered in primary care and is associated with significant morbidity that extends beyond the skin manifestations. Psoriasis is associated with an elevated risk of psoriatic arthritis, cardiovascular disease, obesity, insulin resistance, mental health disorders, certain types of malignancy, inflammatory bowel disease and other immune‐related disorders, and hepatic and renal disease. Enhanced recognition of these comorbidities may lead to earlier diagnosis and potentially better overall health outcomes. Psoriatic nail involvement, severe skin disease and obesity are associated with a greater risk of psoriatic arthritis. Individuals with psoriasis should be routinely screened for psoriatic arthritis to allow for early intervention to improve long term prognosis. Life expectancy is reduced in people with psoriasis due to a variety of causes, with cardiovascular disease and malignancy being the most common aetiologies. Psoriasis affects several factors that contribute to worsened quality of life and increased risk of depression and anxiety. Effective therapies are now available that have been shown to concurrently improve skin disease, quality of life and psychiatric symptoms. As the concordance between psychosocial impact and objective disease severity does not always correlate, it is essential to tailor management strategies specifically to the needs of each individual. Cigarette smoking and excess alcohol consumption are among the most important modifiable risk factors that increase the likelihood of psoriasis development and severity of skin disease. This provides a compelling rationale for smoking cessation and limiting alcohol intake in people with psoriasis beyond their traditional harmful health consequences.

Tom Kovitwanichkanont · Alvin H Chong · Peter Foley

To the Editor: The advent of coronavirus disease 2019 (COVID‐19) has generated an unparalleled level of interest from the medical and non‐medical community. As clinician‐scientists, we watch in astonishment at the exponential growth of academic publications in journals. In January 2020, PubMed saw a sharp rise in the number of publications related to COVID‐19, which continues to grow (Box). We could not help but wonder if this has generated a race to publish. Of course, publishing is crucial to help confront one of the most devastating global health issues of the century. However, it is well recognised that external pressures to publish can muddle the intrinsic pursuit for scientific curiosity and excellence,1 and COVID‐19 has certainly provided the incentive for many clinicians and scientists alike to seek rapid publication. This may, unfortunately, fuel competition in the research/publishing field, which was exemplified by the concerning lack of research collaborations when humans were faced with natural disasters,2 including the 2003 severe acute respiratory syndrome coronavirus (SARS‐CoV) outbreak.3 The urgent nature of this situation means a number of preliminary studies and publications on COVID‐19 are fast‐tracked through the peer review process — or not at all — in the hope of rapidly publicising important findings, opinions and experiences. However, hastily penned observations may mislead and do more harm than good. A recent non‐peer‐reviewed publication on a preprint server likening SARS‐CoV‐2 structurally to the human immunodeficiency virus (HIV) was quickly retracted after the scientific community highlighted serious flaws in the study.4 Furthermore, a preliminary study5 supporting the use of hydroxychloroquine as a COVID‐19 treatment prompted a flurry of off‐label use and media attention. The study was later criticised as being too small and biased, and provided insufficient evidence to recommend its use.6 In summary, rapid publishing allows extensive dissemination of knowledge and sharing of experiences; yet the astute clinician needs to keep an open mind and analyse what is being published, for this cannot take the place of rigorous scientific evaluation and best clinical practice. This is a challenging time in the academic world and COVID‐19 will, no doubt, test our abilities to untangle the vast range of literature available. Box – Monthly and cumulative published articles on coronavirus disease 2019 (COVID‐19)* * We conducted an online search in PubMed and included all articles with the terms “coronavirus”, “COVID‐19”, “COVID” and/or “SARS‐CoV‐2”. The information is correct as of 30 April 2020.

Adrian YS Lee · Ming‐Wei Lin

In reply: Lee and Lin raise an important point about the need for caution in interpreting rapidly published articles in the era of coronavirus disease 2019 (COVID‐19). At the Medical Journal of Australia, we are acutely aware of the need to balance rapid dissemination of key data with the need to maintain our usual high standards of quality and accuracy. We have taken the view that in these unprecedented times, rapid sharing of information is critical, but we recognise the risk of errors this infers. In response, we have implemented a preprint and rapid review process for selected manuscripts of an urgent nature (Box). In order to minimise the risk of errors, all manuscripts are carefully reviewed by myself, our team of experienced and medically qualified editors and, where appropriate, our consultant biostatistician, before being selected for preprint in the MJA. Only where the editorial team have a high level of confidence in the validity and importance of the article will it be selected for rapid preprint publication. Before full acceptance of the manuscript to be published online and in print and, in selected cases, before we accept an article for preprint, we organise a rapid double blind peer review followed by revision in line with our usual stringent processes. In these circumstances, we endeavour to have this process completed within 7 days of preprint publication so that any errors can be quickly identified and corrected. We are very grateful to our reviewers who have been very generous in their assistance with this new process. One final check in our process on full publication is review and editing by our experienced scientific and structural editors, who meticulously check all articles for consistency, accuracy and referencing, while finessing them for readability and clarity of presentation — their expertise is invaluable in ensuring published manuscripts are presented accurately and in the best possible light. We acknowledge that contradiction and error may be inevitable during this rapidly evolving situation but would like to assure our readers that at the MJA, when errors occur, they will be rectified in a timely manner and with full transparency. While we are living in a world of rapid change, our commitment to providing Australian health and medical researchers, clinicians and policy makers with the world‐leading general medical journal they deserve stands strong. Box – MJA process for rapid publication of selected coronavirus disease 2019 (COVID‐19)‐related manuscripts* * Timing is indicative and may vary according to the complexity of the manuscript.

Nicholas J Talley